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Demonstration of Leadership Support  Name of System Quality Council changed to System Quality-Medical Safety Council  Chief Medical Safety Officer named  Medical Safety Committee Established  Monthly reports to the Board  Medical Safety Plan Developed

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First Steps  Common definitions agreed upon  Common database to enter events  Information flows through each site Leadership and Performance Improvement Committee  Information flows from site to system  Critical aspects of safety agreed upon

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What is an Unanticipated Outcome?  A negative or unexpected result stemming from –A diagnostic test, medical judgment or treatment, surgical intervention, or (commission) –The failure to perform a necessary test, treatment, or intervention (omission)

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Why Disclosure?  We are our patient’s advocates  Literature shows that after an unanticipated outcome, the patient and family want to know honestly what happened, and how the hospital is going to prevent future events  Rebuilds trust  Caregiver/Doctor relationship

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JCAHO Standard RI.1.2.2 Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.

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AHA  Develop an institutional policy or position statement on disclosure of unanticipated outcomes  Differentiate between disclosure of an unanticipated outcome and an admission of liability  Determine who will be responsible for informing the patient, and, where appropriate, the family and/or legal representative, about the unanticipated outcome.  Educate caregivers and staff about your organization’s policies and procedures covering this issue, and consider communications training for those charged with disclosing unanticipated outcomes  Specify documentation requirements regarding disclosure

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ASHRM  Each Healthcare institution must develop it’s own policy on management of unanticipated outcomes  Disclosure of such information to patients and families must reflect the requirements of applicable law  Differentiate between unanticipated outcome and admission of liability

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For additional detail on implementation of a policy on disclosure of outcomes, consistent with the requirements of this standard:

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Who Will Inform the patient?  The attending physician  May need pre-disclosure conference with Nursing, Risk Management  All patient questions should be referred to the attending physician

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When Should Disclosure Occur?  As soon as possible after immediate needs of patient addressed  Gather facts FIRST  May not have all the facts yet, in which case DON’T SPECULATE! Offer to speak again as facts become known

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Dangerous Abbreviation Intended MeaningMisinterpretationRecommendation UUnitsMistaken as a zero or a four when poorly written, resulting in overdose. (4U seen as "40" or 4U seen as "44") Use units gg MicrogramsMistaken for "mg" when handwritten, resulting in overdose Use mcg q.o.d. or Q.O.D. Every other dayMisinterpreted as qd or qid if the "o" is poorly written. Use every other day or q 48 hours and time/day to begin therapy TIWThree times a weekMisinterpreted as "three times a day" or "twice a week" Use three times a week ccCubic centimetersMisread as "u" (units)Use mL AU AS AD Both ears Left ear Right ear Misinterpreted as "OU", "OS", and "OD".Use both ears, left ear or right ear OU OS OD Both eyes Left eye Right eye Misinterpreted as "AU", "AS', and "AD"Use both eyes, left eye or right eye

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Moderate Sedation  Moderate sedation/analgesia describes a drug- induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

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Moderate Sedation Patient Evaluation Standards  History and Physical includes: –abnormalities of major organ systems with specific focus on the cardiopulmonary history –pregnancy status –previous adverse experiences with sedation/analgesia, as well as anesthetic techniques –current medications and drug allergies/adverse reactions –time and nature of last oral intake of foods, fluids, etc. –history of tobacco, alcohol, or substance use or abuse

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Moderate Sedation Patient Evaluation Standards  Focused physical exam that minimally includes an evaluation of the airway and auscultation of the heart and lungs.  Assignment of ASA Classification of Physical Status  Pre-procedure laboratory and diagnositic testing guided by the patient’s underlying medical condition.  History and physical examination are valid up to 30 days prior to the scheduled procedure. Verification and review of this information is necessary immediately prior to the provision of moderate sedation.

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Moderate Sedation Discharge Criteria  Following the provision of moderate sedation, patients are monitored until they are suitable for discharge: –Level of consciousness and hemodynamic/respiratory variables evaluated and no longer at risk for sedation and cardiorespiratory depression. –For patients who received pharmacologic antagonists, post- procedure monitoring should continue for a sufficient period of time to detect and appropriately treat its recurrence.  Discharge criteria that pertain to the patient population and specific procedures is developed: –A qualified physician or registered nurse should be in attendance until discharge criteria are fulfilled.